Abstract
Dacryocystorhinostomy (DCR) is a surgical procedure in which a connection is established between the lacrimal sac and the nasal cavity in an effort to bypass an obstruction of the distal lacrimal apparatus. Endoscopic endonasal DCR (EEDCR) is a minimally invasive technique used to achieve this goal. In patients with altered anatomy, EEDCR can be challenging. Here, we describe the use of canalicular transillumination with EEDCR in three cases, and discuss the benefits of this technique.
1
Introduction
Dacryocystorhinostomy (DCR) is a surgical procedure whereby a connection is established between the lacrimal sac and nasal cavity in an effort to bypass distal lacrimal apparatus obstruction. Endoscopic endonasal DCR (EEDCR) is a minimally-invasive technique introduced in the 1980s. In patients with altered anatomy, EEDCR can be challenging. Here, we describe the use of canalicular transillumination with EEDCR in three cases, and discuss the benefits of this technique compared to standard EEDCR.
2
Illustrative cases
2.1
Subjects
Three female patients with nasolacrimal duct obstruction in the setting of distorted sinonasal or lacrimal system anatomy were reviewed retrospectively. The first, a 33-year old woman, had previously sustained an iatrogenic skull base injury while undergoing right-sided EEDCR, necessitating intraoperative rhinologic consultation and emergent endoscopic repair of the defect. Grossly abnormal endoscopic and radiographic anatomy was noted, and a diagnosis of ozena was ultimately established . Two years later, the patient developed nasolacrimal duct obstruction. Given her history of previous skull base defect and abnormal endoscopic and radiographic anatomy, a transillumination-guided EEDCR (TG-EEDCR) technique was performed successfully ( Fig. 1 ). The second patient was a 71-year-old woman who developed recurrent epiphora after previously undergoing right-sided open DCR. Attempts at recanalizing the fistula under endoscopic visualization were challenging due to excessive scarring and anatomic distortion. TG-EEDCR served to delineate a path through the dense scar present within the nasal aspect of the surgical site leading to a successful procedure. The third patient was a 26-year old woman who had previously undergone right-sided endoscopic modified medial maxillectomy for resection of a poorly differentiated neuroendocrine carcinoma of the maxillary sinus. She received postoperative chemoradiation and subsequently developed canalicular stenosis as well as stenosis of the nasolacrimal duct. Attempts to stent the obstruction failed to improve her symptoms, and a TG-EEDCR was successfully performed. Institutional Review Board approval was obtained at Rutgers New Jersey Medical School.
2.2
Surgical technique
The patient is positioned supine with the neck in a neutral position. The face is prepped and draped in a sterile fashion using half-strength povidone–iodine solution. Topical oxymetazoline hydrochloride 0.05% is applied intranasally. The nasal cavity is examined with a rigid 30° endoscope. Submucosal infiltration of 1% lidocaine hydrochloride with 1:100,000 epinephrine solution is carried out at the lateral nasal wall, middle turbinate and uncinate process. In order to pinpoint the lacrimal sac and outline the lacrimal system, a 20-gauge vitreoretinal surgery light pipe (Alcon Laboratories, Fort Worth, TX; Fig. 2 A ) is passed through the lacrimal canaliculi ( Fig. 2 B). Under direct endoscopic visualization with a 30° endoscope (Karl Storz and Co., Tuttlingen, Germany), the location of the nasolacrimal sac is localized ( Fig. 2 C). The light intensity on the endoscopic tower unit is dimmed to minimal endoscopic light intensity ( Fig. 2 D), allowing for better visualization of transilluminated lacrimal system. A flap is elevated over the region of greatest light intensity; the underlying bone is removed with forceps or drilled. Once sufficiently open, the lacrimal sac is marsupialized, and egress of tears into the nasal cavity confirmed. A Crawford tube is then inserted to stent the canaliculi.
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